This article is part of our October 2021 special issue. Download the full issue here.
In this interview, our editor-in-chief, Tina Kaczor, ND, FABNO, speaks with Aminah Keats, ND, FABNO, about breast cancer disparities in African American women. Keats is a practicing naturopathic physician at Capital Integrative Health in Bethesda, Maryland, and is also vice president on the board of directors for the Oncology Association of Naturopathic Physicians (OncANP).
Approximate listening time: 37 minutes
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Tina Kaczor, ND, FABNO: Let’s start by talking about incidence and mortality from breast cancer. What is the latest data telling us?
Aminah Keats, ND, FABNO: This topic is something that is just so near and dear to my heart. I'm so happy to be here and to participate in this discussion. When it comes to breast cancer incidence, the percentages of White women compared to Black women are pretty close. White women have the highest incidence of breast cancer, and Black women closely trail behind. Now, when you look at that same data from 10 or 20 years ago, that gap was wider, but that percentage has increased for Black women. But when you look at the mortality rates, numbers differ pretty significantly. The death rate from breast cancer is about 40% higher in Black women compared to White women. So that gap is pretty significant, and that has actually been pretty consistent over the last several decades.
For women who are aged 40 years of age and younger, the incidence rate actually flips—the percentage of breast cancer in Black women is higher compared to White women. However, that mortality gap across the board is consistent.
Kaczor: We know there are certain things that are predictive or at least a prognostic indicator for women. There are higher rates of death with certain subtypes. Can you talk a little bit more about cancer subtypes and the direction that the data goes?
Keats: When it comes to that tumor and biology piece, when we look at the subtypes, ER-/PR-positive and HER2-negative is most commonly diagnosed in women across the board of all races and ethnicities. That subtype has the best kind of prognosis. However, that particular subtype is lowest in Black women, which is very interesting. It's definitely something to pay attention to. We know that the most aggressive subtype is triple-negative: ER-negative, PR-negative, and HER2-negative. That is the most aggressive, with the poorest prognosis, and that is actually highest in Black women.
So out of the breast cancers diagnosed in Black women in this country, triple-negative disease actually accounts for about 20% to 21%, and that is probably about double compared to other populations in this country. Obviously that plays a role in the disparity.
Kaczor: It’s poignant to hear Black women under the age of 40 have a very high rate of death from breast cancer compared to their White counterparts. Is there any advice you would give clinicians for their young Black patients? Should we be screening earlier?
Keats: That's a really great question. There are no definitive guidelines for that, but there's definitely a need for more individualized research. In terms of screening, we need to be careful about increased radiation exposure, etc. But if there is a strong family history and other kinds of things that we might be concerned about, we should definitely be an advocate for our patients for early screenings if they're warranted based on the current guidelines.
I would also pay closer attention to the laboratory evaluation, like looking at estrogen profiles, insulin resistance versus insulin sensitivity, inflammatory markers. Then looking at things like stress management and cortisol levels. So really taking all of those things into account, because in terms of the contributing factors, those are the kinds of things that could potentially manifest and have an impact on that disparity.
Kaczor: Can you talk about socioeconomic barriers to care?
Keats: When you look through the literature, the socioeconomic piece is probably the most commonly named factor that we see. But what's interesting is when we look at some of the data, even when that is accounted for, there's still a racial difference. When it comes to lack of resources, the obvious question is, are you able to afford insurance? And if so, what is the quality of that insurance, or is the insurance through the state perhaps? How does that compare to private insurance? That can definitely have an impact there.
When you look through the literature, the socioeconomic piece is probably the most commonly named factor that we see. But what's interesting is when we look at some of the data, even when that is accounted for, there's still a racial difference.
A lack of resources can also affect transportation. Suppose the medical facility is far from home—how do you afford to travel there? And if you have children, you're having to be concerned about childcare. For women working hourly jobs, can they afford to have their hours cut for testing, screening, or treatment? When you're thinking about needing money for food, bills, etc., sometimes that can be a challenge.
The other thing is the lack of trust in the healthcare system that has been present within the African-American community for centuries. That plays a factor as well, just as far as trusting your medical providers. All these things combined, I think definitely drop into that larger bucket.
Kaczor: You talk about tumor biology in a way that’s enlightening and clinically relevant. Could you give us a little overview of that aspect?
Keats: Absolutely. As I mentioned, that big, important factor that stands out is the prevalence of triple-negative disease. What's really interesting is that when you look at women in West African countries, which is the origin of most African Americans in this country, that triple-negative prevalence is very similar. Even though their incidence of breast cancer is not as high, their percentages of triple-negative disease, just like African American women, are very high. Also there's a higher rate of early diagnosis before that 35 to 40 year age range.
Another interesting thing is that with HER2-positive versus -negative, there's no difference between the races; it's more with that ER/PR. Other molecular characteristics would include things like increases in p53 expression, greater mitotic indexes (which have been associated with poor prognosis), more aggressive disease, and greater potential for a metastatic spread. It's really interesting because even when you think about, let's say the socioeconomic factors, that tumor biology is something that you can't shift. So even if you are able to provide all the resources in the world, the tumor biology is a constant.
Kaczor: One of the biological aspects of a tumor with breast cancer that we talk a lot about is the ER/PR status. You say that in the biology of the individual person with the diagnosis, there's differing estrogen profiles. Can you talk about that a little bit?
Keats: Some of the data does reveal that estradiol levels may be higher in African American women. In a study involving teenage girls whose menstrual cycle started earlier, estradiol levels were higher, and weight gain was more advanced. In a couple of other studies involving adults, Black women had higher levels of estradiol across the board.
Other conditions, like osteoporosis, are less prevalent in Black women. But uterine fibroids are very common in Black women compared to other groups. We may want to think about focusing more on hormonal metabolism and elimination in this patient population. I know that we do that quite a bit across the board in breast cancer, but maybe really prioritizing that more a bit in Black women.
Kaczor: What is popularly called estrogen dominance.
Kaczor: It is interesting on the heels of another risk factor—obesity and insulin resistance.
Keats: What's really interesting about the insulin resistance piece is that when you look at the literature, it's not necessarily tied to obesity and Black women. Black women have a higher risk of insulin resistance regardless of the BMI. Matched with White women with same age, same BMI, Black women have a higher risk of insulin resistance. That is something to pay attention to and perhaps evaluate, even in our patients who don't present with obesity.
Kaczor: So clinically, that would be a tool that could be used throughout one's life—just check the glycohemoglobin as a routine lab?
Keats: Exactly. I always check for fasting insulin as well.
Kaczor: Do you do C-reactive protein routinely?
Keats: Absolutely: CRP, ESR, IL-6 often, reviewing N/L ratio. Even with the obesity picture, what's interesting about that is BMI is the standard measurement used to evaluate for obesity, but that is not necessarily the most accurate source to evaluate obesity in each group. For example, in Black people in general, Black people tend to have larger bones, denser muscles, different fat distribution. The percentage of Black women who are categorized as obese may not be 100% accurate, or maybe that needs to be adjusted.
Going back to the insulin resistance piece, there could be a connection with that and fat distribution specific to Black people versus White people. For example, subcutaneous adipose tissue versus visceral adipose tissue and the percentages between those 2—there's a connection there. Also distribution of gluteal-femoral distribution is different in African-American women compared to other groups. And insulin resistance is one hypothesis to explain that.
Kaczor: Can you talk more about stress as a possible contributor to the higher rates?
Keats: Stress contributes to everything for everyone. When we think about the impact of stress on the Black community, we have to think about the larger historical view around that. There are different layers. That could be around structural racism and the role that that plays psychologically. That could be around political stressors. That can be around neighborhood discrimination. That can be around environmental stressors, whether that be just actual physical stress within your environment or even pollutants within your environment. So just putting all these things together and the impact that it has mentally, when you think about that connection on a molecular level, when we think about epigenetics and the role that that plays, I think that's definitely something to take into account.
I definitely found that in the literature. Even when you date back to studies during the Jim Crow time, which was a time with very repressive laws that significantly impacted the lives and the livelihood of Black people in this country, I actually found studies looking at breast cancer specifically, showing that women who were exposed to this environment had a higher risk of developing ER-negative or triple-negative breast cancer. So definitely again, something to pay attention to. I mentioned before in terms of evaluation, some of us will do cortisol testing, some of us will just do our own evaluation, counseling, but definitely taking that into account when it comes to creating a whole integrative complete treatment plan for our patients.
Kaczor: If you’re seeing someone with an established diagnosis and you’re looking to prevent recurrence, what labs would you run?
Keats: Outside of the foundational labs that we all know, I would run CBC with differentials, comprehensive vitamin D, and inflammatory markers (CRP, ESR, LDH). I’d look at glucose regulation, so along with fasting glucose, also hemoglobin A1c and insulin levels. I would probably look at leptin as well. As I mentioned, the hormonal aspect of things is important, so I’d look at the metabolism of estrogens, and I’d look at cortisol, too. I'm thinking of the DUTCH test specifically and that layout. Naturopathic and integrative care is all about individualized care, so as other things pop up in the interview, whether it be comorbidities or symptoms that a patient presents with, of course we add on to that.
Kaczor: If you did see a high CRP or ESR, what are some things you might do?
Keats: We're so lucky because there’s so much creativity within the naturopathic field. I like to start with just the foundational things. That stress piece is definitely important, so really focusing on that. Focusing on sleep hygiene and nutrition, and then building from there. We know that food timing is important as far as intermittent fasting, if we think that that's appropriate, that can definitely support a time inflammatory pathway. Of course, supplementation. So all the heavy hitters like curcumin and fish oil and grapeseed extract. Those are the main things that I would go to. And then again, just building all of that based on the specific patient presentation.
Kaczor: Is there anything really specific that we need to drill down to look at in Black women specifically when it comes to their tumor biology?
Keats: I do think it's important to be more aggressive with Black women with breast cancer. As I mentioned, even for Black women who present with ER-positive, PR-positive, HER2-negative (the better prognostic subtype) their risk of death is still higher, even though it's not an aggressive subtype compared to the others. Also, even when you look at the Oncotype DX to determine the risk of occurrence and aggressiveness of early stage breast cancer, even for Black women who have matching scores, their risk of death is still higher.
I think that it's important for us to be an advocate for our patients, because sometimes they may not recognize red flags that we're able to catch quickly. And we can inform them about clinical trials. When you look at clinical trials throughout the world, the people of the African diaspora are not well represented. Encouraging them to participate if we think it's appropriate may be beneficial to their survival.
Kaczor: Great point. Is there anything else you'd like to share with our listeners?
Keats: One thing that I didn't mention about tumor biology was around PTEN and mTOR. I was so desperate to find something specific, concrete in the literature. I did find a couple of studies looking at PTEN, the tumor suppressor gene, showing that it's expressed less in Black women compared to White women. Some treatment strategies we may want to implement include encouraging the expression of that particular tumor suppressor gene. The data shows things like curcumin and certain dietary habits, things like DEM and some other nutrients, may help to support that. In addition, the mTOR pathway tends to be more activated in Black women compared to White women. So thinking about natural things that may potentially inhibit mTOR expression is important from the tumor biology aspect.
About the Expert
Aminah Keats, ND, FABNO, received her undergraduate degree in psychology from Spelman College and completed premedical coursework at Rutgers University. After completing her naturopathic medical training at the University of Bridgeport College of Naturopathic Medicine, Keats completed a 2-year, hospital-based residency in naturopathic oncology at Cancer Treatment Centers of America (CTCA). She then continued her work at CTCA as a naturopathic oncology consultant and director of naturopathic medicine. She currently practices naturopathic medicine and specializes in naturopathic oncology at Capital Integrative Health in Bethesda, Maryland. Keats also serves as a faculty member at Maryland University of Integrative Health. She is a member of the American Association of Naturopathic Physicians, the Oncology Association of Naturopathic Physicians, and member of the OncANP Board of Directors. You can find Keats on Facebook and on Instagram @draminahkeats or at her website: drkeats.com.